Health Inequalities : Health Inequalities - Policies to reduce health inequalities

WHO Policy

WHO draws Europe’s attention to the need for policies to reduce health inequalities

European member states are increasingly implementing policy measures aimed at reducing health inequalities (Judge et al., 2006). The World Health Organisation laid much of the foundation for this growing interest in September 1998 by approving a new health policy framework for the WHO European region entitled Health 21. This policy document identified equity in health as a basic human right, set a clear quantitative details equity target for the European region and offered the WHO European region practical policy advice on how to achieve this target (WHO, 1998a). It built on the earlier established WHO Health for All Policy, in which the WHO defined the main social target for its member states as the attainment of a level of health that would allow all people to lead a socially and economically productive life by the Year 2000- the so-called Health for All Policy (WHA, 1977).

WHO prioritises health equity through two initiatives

The WHO has also helped prioritise health equity in its member states by undertaking the following two initiatives:

the WHO-Europe Programme Socioeconomic Determinants of Health, led by the European Office of Investment for Health and Development, which is supporting countries in the WHO European Region to integrate social and economic determinants of health into their development strategies; and
the Commission on Social Determinants of Health, a global WHO initiative, which aims to assist countries and global health partners to address socio-economic and environmental factors that can lead to health inequalities, such as unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems.

The WHO Commission on Social Determinants has also commissioned various useful publications on health inequalities, including, for example:

Challenging Inequity through Health Systems (Gilson et al., 2007)
Social determinants of health. The solid facts (Wilkinson & Marmot, 2003)

EU Policy

EU Health Strategy and Public Health Programme support reduction of health inequalities

The EU has shown a growing interest in health inequalities, which has recently led to it including specific health equity objectives within both its new Health Strategy and Public Health Programme. The Together For Health Strategy (2008-2013) identifies the reduction of inequities in health, both between and within member states as an important objective to be achieved within the framework of the stategy's first principle of 'shared health values' (EC, 2007). In the current Public Health Programme for 2008 to 2013 the EU identifies 'the attainment of a high level of physical and mental health and well-being and greater equality in health matters throughout the Community' as its overarching aim (EC, 2007a).

Much of this growing interest at an EU level can be attributed to the engagement of the UK Presidency of the EU, who in 2005 made the reduction of health inequalities a major focal point for the EU, by hosting a special Tackling Health Inequalities Summit in London. This summit was attended by representatives from all 25 member states, the European Commission, the World Health Organization and experts in public health from across the world. As part of its Presidency, the UK also commissioned two important health inequalities publications:

Health Inequalities: Europe in Profile (Mackenbach, 2006); and
Health Inequalities: A Challenge for Europe (Judge et al., 2006).

EU encourages integration of health equity considerations into non-health policies and legislation

The EU has also supported the reduction of inequalities by promoting the integration of health equity considerations into non-health policies and legislation. In 2006 the Council of the European Union adopted the Health in All Policies conclusion, in which it urges both EU institutions (such as the EU Commission and the EU Parliament) and EU member states to integrate health equity considerations into the development of their policies and legislation and to promote cross-sectoral engagement to achieve greater health equity (EU, 2006).

EU social inclusion policy supports reduction of health inequalities

The EU has also contributed to the reduction of health inequalities through the promotion of social inclusion within its member states, via the Community Action Programme to Combat Social Exclusion (2002 to 2006) and the current PROGRESS programme. These Programmes have encouraged EU member states to adopt national strategies to prevent and combat poverty and social exclusion and to learn from each other through the sharing of good practices and knowledge. Recent progress reports have shown that this engagement at an EU level has fostered greater recognition of the problem of social exclusion within EU member states and first steps toward the development of plans to tackle the problem. As social exclusion and poverty are key contributors to health inequalities, the EU’s engagement at this level has the potential to help reduce the health gap between different socio-economic groups within the EU (BZgA, 2008).

EU Public Health Programme initiatives promote sharing of good practice and knowledge

In recent years the EU has funded a number of initiatives through its Public Health Programmes that promote the sharing of good practice and knowledge on health inequalities and offer the EU member states practical policy advice. These include:

Closing the Gap: Strategies for Action to Tackle Health Inequalities in the EU (2004-2007), which led to the establishment of a health inequalities knowledge portal offering practical (policy) information and guidance to the EU and its Member States on tackling health inequalities;
Eurothine, which has developed and collected health inequality indicators, assessed evidence on the effectiveness of policies and interventions to tackle the determinants of health inequalities, made recommendations on strategies for reducing health inequalities and developed a proposal for a permanent European clearing house on tackling health inequalities.
DETERMINE (2007-2010), a project with the objective ‘to generate greater understanding and to change conceptions and approaches amongst policy makers and practitioners, so that all policy sectors take the issues of health and health equity into consideration when developing policy’.

National Policies and Strategies

Comprehensive cross-sectoral policy approach required to address broad range of determinants

The poorer health of the more vulnerable socio-economic groups in society can be attributed to a broad range of mediating factors or determinants, including:

social and economic conditions (e.g. poverty, lack of social support);
health and social support systems (e.g. unequal access to treatment); and
unhealthy lifestyles of the more vulnerable groups in society (e.g. smoking).

Consequently, there is general agreement that a comprehensive national policy approach is needed to tackle the health gap between the lower and higher socio-economic groups. This comprehensive approach should (Mackenbach et al., 2007a Dahlgren & Whitehead, 2007 WHO, 1998a):

include interconnected upstream and downstream interventions that seek to bridge the health gap between the lower (e.g. those with a lower level of education and income) and higher socio-economic groups in society; and
be supported by a range of sectors and agencies from both within and outside of the health sector (e.g. through partnerships and joint goals).

The text to the right offers an insight into how such an approach can be taken in practice.

Country and region-specific analyses should guide policy development

The contribution of determinants and diseases to health inequalities differs greatly from country to country and region to region. For example, socio-economic inequalities in obesity are more pronounced in Southern Europe than in the Eastern and Baltic regions of Europe (Mackenbach et al., 2007a). The development of policies to tackle health inequalities should therefore be guided by country- and region-specific analyses that determine what interventions offer the best potential to narrow the country- or region-specific health gaps between particular socio-economic groups (Mackenbach et al., 2007a; WHO, 1998a). Tools such as Health Impact Assessment and the Eurothine instrument to assess the transferability of foreign health inequalities interventions provide a useful starting point for this analysis.

National policies should be supported by quantitative health equity targets

National policies on health inequalities should also be supported by specific, measurable, achievable, realistic and time-based equity targets. Such targets enable the progress toward greater healthy equity to be monitored at a national level and the effectiveness of the chosen policy approach to be evaluated on a regular basis. At present only a small group of EU member states, including Finland, Ireland, the Netherlands, Scotland, Sweden, Wales and the UK have set specific targets to monitor their progress toward greater health equity (Judge et al., 2006; Mackenbach et al., 2007a). Many of these countries have used the details World Health Organisation health equity target for the European region as inspiration and have adapted this target to their own particular national situation.

Varying degrees of policy engagement at EU Member State level

Currently EU member states are at different stages in establishing policies and strategies to reduce these inequalities. They have either (Costongs et al., 2007; Judge et al., 2006):

implemented policies or legislative measures that are directly or indirectly related to improving the health of vulnerable groups to some degree, but not yet policies with the specific aim of reducing health inequalities (e.g. Belgium, Cyprus, Greece);
included or are in the process of including the reduction of health inequalities as a specific aim in their national or local level policies (e.g. Denmark, Estonia, Finland, France, Germany, Hungary, Italy, Latvia, the Netherlands, Poland, Portugal, Slovak Republic, Spain);
adopted or are in the process of adopting cross-government strategies or policies specifically aimed at tackling health inequalities (e.g. England, Republic of Ireland, Northern Republic of Ireland, Norway, Scotland, Sweden, Wales).

Policy approach taken in United Kingdom can serve as inspiration for other European countries

The government of the United Kingdom (UK) has taken decisive action at a national level to tackle the inequities present in its country, and can serve as an inspiration for other European countries. It has implemented a specific action programme for tackling health inequalities, namely the Tackling Health Inequalities: A Programme for Action. This is a cross-government strategy that is (Department of Health, 2003a):

backed by twelve government departments;
based on strong local, regional and national partnerships; and
supported by two clear equity targets for the year 2010:

starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between routine and manual groups and the population as a whole.
starting with local authorities, by 2010 to reduce by at least 10 per cent the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators and the population as a whole.

The programme is organised around four themes, which are based on the priority areas that the English government has identified (Department of Health, 2003a):

supporting families, mothers and children – to ensure the best possible start in life and break the inter-generational cycle of health;
engaging communities and individuals – to ensure relevance, responsiveness and sustainability;
preventing illness and providing effective treatment and care – making certain that the National Health Service provides leadership and makes the contribution to reducing inequalities that is expected of it;
addressing the underlying determinants of health – dealing with the long-term underlying causes of health inequalities.

These themes are then further supported by five principles, which are to guide the different participants at a local, regional and national level in tackling the health inequalities in practice (Department of Health, 2003a):

preventing health inequalities getting worse by reducing exposure to risks and addressing the underlying causes of ill health;
working through the mainstream by making services more responsive to the needs of disadvantaged populations;
targeting specific interventions through new ways of meeting need, particularly in areas resistant to change;
supporting action from the centre by clear policies effectively managed;
delivering at a local level and meeting national standards through diversity of provision.

For more detailed information about the English Programme of Action see the UK Department of Health website.